All Posts tagged rehab doctor

Principles of a Rehab Specialist: From Fat Loss to Performance Ready, Part 2

Metabolism and the Benefits of Interval Training

by Jeffrey H. Tucker, DC, DACRB

In the previous article, I introduced you to Sheldon, who has been diagnosed with a pre-insertional tear of the Achilles tendon. Sheldon is now out of acute pain and has to start his exercise training in preparation for playing basketball in the upcoming Maccabi Games.

Eliminate Conventional Aerobics

What led Sheldon to an ankle injury was his personal choice in preparation for the games. He started spending about an hour on the treadmill three days per week and then played basketball another three times per week. He did not properly stretch or warm up prior to his activities. The probable mechanism of injury to his ankle was repetitive stress and faulty movement patterns. Sheldon’s diagnosis was a pre-insertional tear in the Achilles tendon. Initially, walking and running were painful. However, he could ride a stationary bike.

One of the first changes I make to a cardio program is to have my clients eliminate conventional aerobics. For example, if a client is spending 60 minutes on a treadmill or elliptical machine, I recommend they spend that hour of time performing: 10 minutes on the foam roll; 10 minutes isolated stretching; 20-25 minutes doing a combination of body-weight exercises, resistance exercises and/or lifting free weights; and 15-20 minutes of cardio training, especially using interval training techniques.

The foam roll is used as an inhibitory technique to release tension and/or decrease activity of overactive neuro-myofascial tissues in the body. After using the foam roll, clients are instructed to participate in static stretching of muscles to increase the extensibility, length and range of motion of neuromyofascial tissues in the body.

The next phase of the workout is muscle-activation techniques, often performing body-weight exercises. These exercises are used to increase intramuscular coordination and strength. Squats, lunges, push-ups and step-ups are examples of dynamic movements. When I train my clients to lift free weights, I want them to lift heavy weights. When I teach free-weight training, I recommend creating circuits of five exercises, performing six repetitions of each exercise and then performing the circuit three times. The sixth rep of each set should be difficult to complete if you are using the correct amount of weight.

In three separate half-hour, in-office sessions, (once per week for three weeks) I can teach my clients approximately 15 different resistance, body-weight and/or free-weight exercises. At the end of the three sessions, they have learned and practiced enough to perform a 15-minute, 30-minute or 45-minute whole-body, customized workout routine. The amount of time they work out and spend on the home program depends on the number of sets they perform. They can adjust this to their own schedule.

If clients are not ready to lift free weights, I use a fitness tool that combines a stick and exercise bands into one effective workout. You can do hundreds of different exercises and combination movements to improve strength and flexibility. Every Tuesday and Friday morning, I teach a small-group exercise class. My experience has shown that resistance-band or resistance-bar exercises can be performed for one-minute intervals and then changed to the next exercise for the next minute. This routine can be continued for 20-45 minutes. This provides a great cardio, strength and flexibility workout.

Teach Interval Training

Sheldon needed to get cardio fit and “court ready” for the basketball tournament. The best choice of training for his cardio is interval training. Interval training is broadly defined as alternating brief periods of very high-speed or high-intensity work, followed by periods of rest or very low activity. Simply put, interval training is based around the concept of “Go fast, then go slow, then repeat.” You can perform interval training routines on pretty much any machine you want, such as a treadmill, bike or elliptical machine, and it can apply to almost any sport (swimming, cycling, running).

In interval training, high heart rates during work periods and low heart rates during recovery follow each other. This not only results in increased cardiovascular strengthening, but also increases the energy expended per minute, increasing thermogenesis and thus resulting in increased fat loss. Just remember, the concept of interval training is to go fast and then go slow.

If you are dealing with an unfit client, I don’t recommend they run to get fit. They need to start a walking routine first. Once they are fit, they can run. Typically when a person decides to start an exercise program, they usually think of walking as the major form of exercise. Walking is an ideal place to start. How do you apply interval training? If you’re in good shape, you might incorporate short bursts of jogging into your regular brisk walks.

In my home gym, I have an elliptical machine for my interval training. For example, I warm up at a speed of 5.5 for five minutes and then perform short, fast (speed of 8-10) bursts for 30-60 seconds. I slow down for a minute or two and then repeat the fast burst again. This is performed for 15-20 minutes. If you’re less fit, you might alternate leisurely walking with periods of faster walking. For example, if you’re walking outdoors, you could walk faster between certain landmarks.

Have you ever noticed when people continue to do the same walk, day in and day out, and do not add periods of short bursts to increase metabolic activity to improve their fitness level, they simply stay at the same weight, BMI and body composition? If clients are just beginning an exercise routine, I also suggest they include bicycling in their routine. Since bicycling allows for maximum metabolic disturbance with minimal muscular disruption, metabolic rate and exercise activity efficiency easily can be increased. To apply interval training to cycling, you could pedal all out for 60 seconds and then ride at a slower pace while you catch your breath for the next two to four minutes. Try to keep the bursts of speed at around 90 percent to 100 percent of maximum effort.

An example of an interval routine for runners is to sprint for 20 seconds, rest 10 seconds, repeat four to eight times; or sprint 15 seconds, rest 5 seconds, repeat four to six times.

The Benefits of Interval Training

Major increase in fat loss. In a study done by Tremblay, et al., two groups were assigned different training regimens.1 Group A performed regular moderate intensity cardio (like jogging or bicycling) for 20 weeks and Group B performed interval training routines for 15 weeks. The results of each group were recorded. Group B lost nine times more fat than Group A in five weeks less time.1

Increased lactic acid threshold. Lactic acid threshold indicates how fast your body can remove the lactic acid in your muscles. When your body can remove lactic acid more efficiently, you can work the muscles at a higher intensity for a longer period of time before they become fatigued.

Shorter workouts. If you crank up your exercise intensity using interval training, you can work out in less time and accomplish more compared to performing steady-state cardio. It appears interval training burns more fat than regular moderate-intensity cardio. The rationale is that recovery of metabolic rate back to pre-exercise levels can require several minutes for light exercise and several hours for hard intervals. This phenomenon is called excess post-exercise oxygen consumption (EPOC). Intense exercise of a significant duration may cause EPOC or afterburn. This means extra calories are burned after an intense exercise bout. This indirect expenditure of energy has been shown to last from 30 minutes to many hours post-exercise.

Don’t forget that the training effect increases faster with increased intensity than with increased duration. A long-duration, low-intensity workout will not necessarily result in a high training effect, while a short, high-intensity workout may produce a high value. You need to develop an aerobic base in your fitness clients, but you must progress to intervals if you want real results in both fitness and fat loss. The bottom line is: The higher the intensity, the more calories will be expended. The more energy expended per minute, the more efficient your exercise time will be for fat loss. By the way, Sheldon’s team went on to win the men’s basketball championship.

Reference

  1. Tremblay A, Simoneau JA, Bouchard C. Impact of exercise intensity on body fatness and skeletal muscle metabolism. Metabolism, July1994;43(7):814-8.
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Principles of a Rehab Specialist: From Fat Loss to Performance Ready, Part 1

by Jeffrey H. Tucker, DC, DACRB

This article is a real story about a client of mine, Sheldon, whom I am proud to call a very good friend. Last year, I was excited to find out that he was invited to play in the 2007 Maccabi Games (www.jccmaccabigames.org).

I want to personally share his story with you while educating you on the principles of rehab at the same time. Sheldon was given an opportunity to live a dream of playing in a basketball competition that few will ever experience. He came to me feeling confident with our past experiences I could help him recover from a serious injury and get him in shape for the tournament in about 12 weeks’ time. Like every client, Sheldon’s recovery and therapy required customization.

In mid-September 2007, Sheldon, a 49-year-old male presented to my office with left lower-posterior leg and ankle pain made worse with walking. He indicated to me that the pain was in the Achilles tendon region and attachments at the calcaneus. He had been recently invited to play for the U.S. basketball team at the 11th Pan American Maccabi Games in Buenos Aires, Argentina, in December 2007. He decided to make the trip to Argentina a family vacation. Sheldon was not unfit, yet he was not in condition for a world-class competition. The ankle injury had occurred as a result of his overexertion in preparing for the tournament.

He came to my office with an immediate goal of pain relief so he could practice basketball again. His bigger goal was a structured exercise program to get him ready for Argentina. The patient was diagnosed with pre-insertional Achilles tendonitis with a partial tear. His past history was remarkable for low back pain and previous diagnosis as a pre-diabetic. The goals of a complete chiropractic/rehabilitation training program for this client were to: decrease pain and body fat, increase strength, endurance, flexibility, lean muscle mass and performance; and prevent injury.

Sheldon’s treatment was guided by measurements such as bioelectrical impedance analysis (BIA), weight loss, heart rate, exercise intensity, ratings of perceived exertion, interval training timing and meal plans. The tools I used to decrease his pain as quickly as possible were a class IV, high-powered warm laser, sound-assisted soft-tissue mobilization (SASTM) as taught by David Graston, joint mobilization/manipulation and myofascial therapy. I had his MD prescribe ketoprofen cream, an anti-inflammatory used to massage into the Achilles area.

As part of his overall program to achieve the above goals, I recommended and initiated food plans, supplementation and a corrective exercise program. Diet is the best tool for fat loss. I have found the Mediterranean diet is easy for clients to follow and offers the best results.

The need for supplements depends upon the individual sitting in front of you. However, there are specific nutrients we can recommend for each individual to take on a daily basis. For example, Sheldon was instructed to take 3 grams of EPA/DHA per day for pain relief and to support joint and bone health, glucose and insulin homeostasis, and the integrity of neurological cells. He was instructed to take daily essential vitamins and minerals, and to increase his protein intake using a bioactive, pure whey protein powder concentrate.

Exercise creates changes in the musculoskeletal system, increasing strength and performance, along with stimulating physiological processes. However, we may not all agree on the best type of exercise to make such changes. In this article and the next, I will discuss these topics and much more, clarifying the connections between fat loss, fat-free mass, exercise and performance.

Measurement and Weight-Loss Basics

Within three weeks, Sheldon was walking without pain. At the end of the third week, he could jog with slight to moderate pain after 10 to 15 minutes of intermittent stops and starts, as in playing basketball. Once his pain diminished enough that he could jog, it was time to get serious and implement a corrective exercise program. We all recognize the value in measuring blood pressure, height and weight. As part of my workup before starting an exercise progression or before starting a weight-loss program, I measure body fat percentage and lean body mass. When I ask a client, “How much do you weigh today?” I often hear remarks such as, “10 pounds too much.” Then I ask, “But how much do you weigh now?” and get the usual response of, “I don’t know, I never weigh myself.”

Maintaining a healthy body weight includes maintaining healthy functioning immune, hormonal and reproductive systems without any traces of an eating disorder. It is also a weight that you can realistically reach and maintain with healthy lifestyle efforts. To effectively manage body weight and body composition, it is important to know your daily caloric requirements. A BIA test can tell us body composition and basal metabolic rate. Accurate assessments using BIA allows me to determine each client’s unique personal caloric requirements and to better plan and evaluate weight management/exercise programs. As mentioned above, I utilize therapeutic lifestyle changes (TLC) including food plans, supplements, exercise and relaxation that can be evaluated using objective measures before and after beginning my nutritional and/or exercise program.

Body Composition Measurements

In my practice, I use a body composition machine, which is a portable, battery-powered bioimpedance analyzer. Patient assessments are conducted using a connection between the analyzer and the wrist and ankle of the patient. Connections to the patient are through standard ECG sensor pad electrodes. Resistance and reactance, the two components of impedance, are measured directly from the body.

On Sheldon’s initial office visit, he was 78 inches tall and weighed 215 pounds. A look at some of the results from Sheldon’s BIA test revealed the following:

Fat Mass (FM) 20.8%
Fat-Free Mass (FFM) 79.2%
Body Mass Index (BMI) 25.5
Intracellular Water (ICW) 56.4%
Extracellular Water (ECW) 43.6%

Body Weight

Body weight is the sum of your body fat or fat mass (FM) and your lean body mass or fat-free mass (FFM). FFM consists of dry lean mass and total body water (TBW). TBW is divided into water inside the cells (intracellular water – ICW) and water outside the cells (extracellular water – ECW). TBW is the sum of intracellular water and extracellular water (ICW + ECW = TBW). Keeping these components appropriately balanced is the key to staying fit and healthy. Compositional imbalance in the body is closely related to obesity, malnutrition, edema and osteoporosis. It also will contribute to suboptimal athletic performance.

Body Mass Index

Body mass index (BMI) is a common measure expressing the relationship (or ratio) of your body weight to your height. BMI is more highly correlated with body fat than any other indicator of height and weight, but it is not recommended for use as the sole measurement of your body composition. It does not apply to infants, children, adolescents, pregnant/breastfeeding women or adults over 65 years of age.1

BMI Measurements and Ranges: You can calculate your BMI using the formula: BMI = weight (kg)/[height (m)].2

BMI <18.5: This calculation may indicate an underweight status and may be associated with health problems for some people. This client may need to have a consult regarding diet or other health-related issues.

BMI of 18.5 – 24.9: This zone is the preferred range as it is associated with the lowest risk of illness. The client is living life in a way that improves health.

BMI of 25 – 27: This zone may be fine if you are physically active. You likely have lots of muscle mass and may be overweight but not overly fat. However, a BMI over 25 may be associated with health problems for inactive people. This client will need to consult with a doctor.

BMI of 27 – 29.9: This is a health risk zone and is associated with increased risk of heart disease, high blood pressure and diabetes. At this point diet, nutrition and exercise must be implemented.

BMI > 30: This is obesity. Clients must be provided with a program of balanced eating, supplements, regular exercise and reduction of stress.

Sheldon’s BMI was 25.5, putting him between 25 and 29.9. Although he is only 0.5 over, this still falls within the overweight range. Being overweight increases your risk for heart disease, diabetes and other serious health problems. I was not concerned about Sheldon being overweight, but I was concerned that he would be under stress from the workouts ahead and was on a tight time schedule to get ready for Argentina. Within the first week of treatment, I had discussed the Mediterranean food plan with Sheldon to promote healing and increase strength.

Table 1: Risks of cardiovascular disease relative to body mass index and waist circumference3

Body Mass Index (BMI) Waist Circumference
Men = 102 cm (40 inches)
Women = 88 cm (35 inches)
Waist Circumference
Men > 102 cm (40 inches)
Women > 88 cm (35 inches)
Underweight = <18.5 Increased Risk? Increased Risk?
Normal weight = 18.5-24.9 Low Risk Low Risk
Overweight = 25-29.9 Increased Risk High Risk
Obese = 30-34.9 High Risk Very High Risk
Obese = 35-39.9 Very High Risk Very High Risk
Extremely obese = 40+ Extremely High Risk Extremely High Risk

The BMI ranges are based on the relationship between body weight and disease and death.4 Overweight and obese individuals are at increased risk for many diseases and health conditions, including hypertension, coronary heart disease, stroke, type 2 diabetes, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, some cancers (endometrial, breast and colon), and dyslipidemia (high LDL cholesterol, low HDL cholesterol or high levels of triglycerides).

Muscle Mass

There are three types of muscle: cardiac, visceral and skeletal muscle. The quantity of skeletal muscle is most affected by exercise, particularly by strength-training programs. By comparing the percentage of body fat mass and skeletal muscle mass in each body component, the level of fatness or obesity can be measured in a more proactive and exact manner. An essential part of my program is to teach my clients how to train and lift free weights. By teaching Sheldon corrective exercises and a free-weight training program, I expect his muscle mass to increase and the body fat to decrease.

We will follow Sheldon’s progress in part 2 of this series and look at metabolism and the benefits of interval training.

References

  1. Mei Z, Grummer-Strawn LM, Pietrobelli A, et al. Validity of body mass index compared with other body-composition screening indexes for the assessment of body fatness in children and adolescents. Am J Clin Nutr, 2002; 75(6):978-85.
  2. Garrow JS, Webster J. Quetelet’s index (W/H2) as a measure of fatness. Int J Obesity, 1985;9:147-53.
  3. Gallager DG, Heymsfield SB, Heo M, et al. Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr, 2000;72(3):694-701.
  4. Prentice AM, Jebb SA. Beyond body mass index. Obesity Rev, August 2001;2(3):141-7.
  5. Gallagher D, Visser M, Sepúlveda D, et al. How useful is BMI for comparison of body fatness across age, sex and ethnic groups? Am J Epidemiol, 1996;143(3):228-39.
  6. World Health Organization. Physical Status: The Use and Interpretation of Anthropometry. WHO Technical Report Series. Geneva: World Health Organization, 1995.
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